Muscular skeletal disorders of the lower limbs (injuries, infection) present as acute onset of toe walking, usually in one leg.

Why do some children walk on their toes?

We do not know why some children with no neurological or muscle disorder, habitually walk on their toes. There is no evidence to support the idea that toe walking is due to a sensory processing disorder.

Children who walk on their toes often have tightness in the calf muscles, but often this is not enough to explain why the child does not adopt a normal heel-toe gait.

The majority of children who walk on their toes do so from when they start to walk independently.

Toe walking may be associated with developmental coordination disorder (DCD). Children with DCD have difficulties with learning new motor skills, are often late reaching the major milestones, and have poor gross and fine motor skills as well as poor ball skills and motor planning difficulties. Their balance is poor and they often trip and fall a lot.

Although there is no research that links toe walking and generalised joint hypermobility, clinical experience indicates that the majority of toe walkers have joint hypermobility with tightness in the iliotibial band and associated fascial structures, along with some coordination difficulties.

Toe walking is often seen in children on the autistic spectrum. The underlying cause is probably the same as for neurotypical children: a combination of coordination difficulties and generalised joint hypermobility.

Most toe walkers can adopt a heel-toe gait pattern

Although the child can walk using a typical heel-toe gait, they find this uncomfortable and tiring. It requires effort and attention, and may cause discomfort in the lower leg.

In fact, most children walk on their toes from the start and never really develop the coordination and balance control needed for a typical heel-toe gait.

The tendency to walk on the toes is worse when the child is tired and does not have the mental or physical energy to adopt a heel-toe gait.

As the leg is moved forwards the ankle is flexed to allow the heel to make contact with the floor. This movement requires at least 90 degrees of dorsiflexion.

900 of dorsiflexion needed for effective heel strike.

Once the foot is flat on the floor, the body moves over the foot which requires an additional few degrees of ankle dorsiflexion.

As the body moves over the supporting foot the amount of dorsiflexion increases.

During the weight bearing phase of the gait cycle, the trunk is body slightly sideways to balance the trunk over the leg. .

This shift requires adequate flexibility in the hip joint - the hip moves into a position of adduction.

When toddlers first starts to walk, they keep the legs wide apart and tip their trunks sideways to maintain balance. It takes practice before the toddler learns to adduct the hip and keep the trunk upright.

Toddlers with tightness in the hip muscles tend to walk with their feet wide apart and also turned out.

Children who toe-walk have tightness in the calf and the hip muscles

When examining a child who toe walks, doctors and physical therapists often emphasize the restricted range of movement in the calf muscles. The restricted movement in the hip muscles is very often neglected, which is a pity because tightness in the iliotibial band is an important underlying factor in ITW.

Calf muscle tightness

The child may have some tightness in the calf muscles which limits dorsiflexion (bending) of the ankle, but very often this movement is not particularly tight.

A child with good flexibility can bend the ankle to 90 plus degree of dorsiflexion.

Children with tight calf muscles can only bend the ankle to 90 degrees or less.

This affects the child's ability to bend the ankle in preparation for heel strike, as well as during the single leg phase of walking.

Hip muscle tightness

Most children who toe walk have tightness in the muscle (and associated fascial structures) that crosses over the side of the hips and knees, called the iliotibial band.

Tightness in this muscle makes it uncomfortable to stand with the knees and feet in line with the hips.

Instead the child stands with the legs wide apart and the feet turned out.

A simple test for iliotibial band tightness

Let your child stand with the feet parallel and about 10 cm apart.

Is this comfortable? Does it feel good or "not nice"? Is it boring? (Children often do not recognize discomfort, but know that something is unpleasant and will often refer to this as boring.)

Next let your child stand with the feet wide apart.

Does this feel better?

Children are usually quite clear about the difference in comfort between the two positions.

How calf and hip muscle tightness affects walking

As mentioned above, when a child walks with typical gait pattern, the ankle has to dorsiflex beyond 900 as the body shifts forwards over the foot during the single stance phase of walking.

At the same time, in order the balance the trunk over the foot, there needs to be adduction of the hip joint.

If a child has tightness in the ankle and hip muscles, this combination of ankle dorsiflexion at 900 plus as well adduction of the hip causes discomfort in the these muscles. Walking with the foot flat on the floor is uncomfortable, with the discomfort often being felt on the outside of the lower leg.

Autism and toe walking

Toe walking is often seen in autistic children. Although this is sometimes ascribed to poor sensory integration or modulation, there is little evidence support for this idea.

It is possible that the toe walking in ASD is associated with the increased occurrence of generalized joint hypermobility, but this has as yet not been investigated.

An autistic child who walks on the toes probably has a combination of joint hypermobility, tight hip and calf muscles, poor coordination of balance and walking as well as a tendency to be very sensitive to discomfort.

What can be done for a child who walks on the toes?

Serial casting

If the calf muscles are very tight and the ankle cannot be bent past 900, then serial casting is the most effective intervention.

A below knee cast is fitted on the child with the ankle flexed as fat as it will go. The cast is replaced at weekly intervals, with the amount of dorsiflexion being increased each time.

Although attention to hip flexibility is not mentioned in most descriptions of serial casting, it is probably a good idea to include a program of hip and knee stretches.

The SfA Training Guide Stretching and Balance Training Program

Research has shown that if a child can dorsiflex the ankle to at least 900, a program of calf muscle and iliotibial band stretching, hip strengthening and balance exercises to train effective active dorsiflexion will usually improve the child's ability to walk with a heel-toe gait.

The SfA program differs from the usual stretching routines prescribed for toe walkers, in that it pays attention to the hip muscles as well as to training balance.

This is not a quick fix program, and will need 15 minutes a day, 4-5 times per week over a period of 5-6 weeks to achieve a good result.

However, a regular 15 minutes-a-day training program has additional benefits: regular exercise doing activities with a goal, that challenge the child and require persistence and tolerance of effort will usually improve your child's capacity for paying attention, working memory and managing emotional responses and general fitness will be improved, and the ability to sit erect will also be improved.

Your exercise program should be fun: children enjoy the challenge of achieving goals, and using the right incentives and feedback motivates a child to work hard.

Active stretching for the iliotibial band and calf muscle

Triangle stretch

This exercise stretches the fascial structures that cross from the lower back, over the back of the hips, knees and ankle joints.

It also stretches the planar fascia under the foot.

Bridging - for stretching the iliotibial band

This exercise stretches the tensor fascia lata and iliotibial bands across the hips and knees. It also strengthens the hip extensor muscles

Standing up and sitting down

This exercise strengthens the hip extensor and knee extensor muscles, and stretches the calf muscles and liotibial band.

As the extensor muscles start to tire, the feet will tend to turn out as the knees are extended. Blocking this outward movement of the feet provides a very effective active stretch to the iliotibial bands as they cross over the knee.

Stepping up

Stepping up with the foot facing forwards and flat on the step, not only strengthens the leg muscles , but also train foot balance and stretches the ankle muscles.

Balance exercises in standing

Balance exercises are very important for training effective balance responses in the ankle joints when balance is disturbed.

These balance responses are most effective when the feet are face more or less straight forwards.

Children who stand with their feet turned out and wide apart often lack effective balance reactions in the ankle muscles.

Exercises to train foot and ankle balance responses

This set of exercises helps the child develop effective and fast balance reactions in the feet.

Ball exercises standing on a step or balance block

Maintaining balance when catching and throwing a ball requires effective small adjustments in the ankles to maintain balance.

Letting the child stand on a small step or a balance block means that the muscles have to work harder to maintain balance.

Standing and bending down to pick up the ball also stretches the calf muscles.

Training standing on one leg

The ability to stand on one leg with the foot facing forwards and the trunk erect and balanced over the foot is important for walking, stepping up and over obstacles and gaps, as well as for kicking a ball.

This set of exercises is graded from easy to difficult, ensuring that every child is able to work on this task and slowly improve balance standing on one leg.

Suggestions for encouraging flat-foot walking

Children who habitually walk on the toes find walking with a more typical heel strike-foot-flat gait tiring and uncomfortable. Even once the child's flexibility and balance abilities have improved, walking with the foot flat requires mental effort. So it is best to start changing from toe walking to foot-flat walking gradually and for increasing distances.

Do not expect your child to start walking with a foot-flat gait all the time. As children get older, they become more aware of their gait and will usually pay more attention to how they walk. when this happens, all the good work you put into improving flexibility, strength and balance will mean that your child has the ability to change his or her gait fairly easily.